Provider Demographics
NPI:1902967912
Name:SUMMERVILLE SURGICAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:SUMMERVILLE SURGICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF BUSINESS
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-851-0200
Mailing Address - Street 1:87 SPRINGVIEW LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8154
Mailing Address - Country:US
Mailing Address - Phone:843-851-0200
Mailing Address - Fax:843-851-9398
Practice Address - Street 1:87 SPRINGVIEW LN
Practice Address - Street 2:SUITE A
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8154
Practice Address - Country:US
Practice Address - Phone:843-851-0200
Practice Address - Fax:843-851-9398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15402174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0766Medicaid
SCGP0766Medicaid
SC4440Medicare ID - Type Unspecified